A program of home visits, partner education, and HIV testing for couples in Kenya was able to double the proportion of men who tested during their partner’s pregnancy, Carey Farquhar from the University of Washington reported at the Conference on Retroviruses and Opportunistic Infections (CROI 2016) in Boston last week. Partners became aware of each other’s HIV status without this being linked to an increase in intimate partner violence.

Whereas HIV testing is widely offered to women attending antenatal clinics, there are fewer opportunities for men to test. In African countries, no more than a third of men take an HIV test during their female partner’s pregnancy, but there are particular advantages to engaging with men at this time.

The male partner may strongly influence decisions affecting women’s reproductive health. Pregnant women who are diagnosed with HIV during individual HIV counseling and testing, without the support of their partner, may be afraid of disclosing their HIV status to him. Moreover, they are less likely to adhere to HIV treatment during pregnancy and other interventions to prevent mother-to-child transmission.

In the case of a couple where the man has HIV and the woman does not, lack of male partner HIV testing may result in the woman seroconverting to HIV-positive during pregnancy or breastfeeding (a period of elevated transmission risk). A woman who has herself just become HIV positive would have a very high viral load, putting her at exceptionally high risk of passing the infection on to her child.

Several interventions have been shown to modestly improve HIV testing rates among male partners, but these have not had the large effect seen in the study presented at CROI. These interventions have included letters to invite male partners to attend HIV testing at antenatal clinics, making antenatal clinics more "male friendly," and adapting post-test counseling for women so that it develops their communication skills and self-efficacy.

The Intervention

Visiting homes, door to door, and offering HIV testing and other health interventions has already proved to be feasible and acceptable in many African countries. In some programs, both members of a couple may be counseled and tested at the same time -- the partners are encouraged to share their test results.

The HOPE program in Kisumu, Kenya, built on this experience. In couples randomized to receive the intervention, women did not take an HIV test at the antenatal clinic, but the couple were given an appointment for a male/female pair of community health workers to make a home visit. Both the male and female partners were offered HIV counseling and testing, with the choice of whether it would be done together as a couple or individually. In addition, the couples received educational messages about HIV, male circumcision, childbirth in health facilities, exclusive breastfeeding, and postpartum contraception.

In those randomized to the control arm, women took an HIV test at the antenatal clinic, were counseled on encouraging their partners to test, and male partners received a letter inviting them to HIV testing. All other aspects of care were identical. At 6 months after the birth, both men and women provided data on outcomes.

A total of 620 women met the study’s eligibility criteria and only 19 refused to take part. Their average age was 25 and almost all were living with their partner. In line with the local HIV prevalence, 1 in 5 women were HIV-positive, with half being diagnosed for the first time.

In the intervention arm, 87% of men took an HIV test, compared to 39% in the control arm. Test uptake was therefore doubled (rate ratio 2.10). Rates of couple testing and disclosure were also significantly higher in the intervention arm:

77% of couples tested together, compared to 24% in the control arm;

88% of women said they knew their partner’s HIV status, compared to 39% in the control arm;

13% of all couples in the intervention arm were identified as having different HIV statuses, compared to 4% of couples in the control arm.

The pre-test and post-test counseling of the program was designed to help couples disclose their status to each other in a safe way and to defuse tensions. Nonetheless, the potential for partner violence is a concern for any couples testing program. Before randomization, 6.5% of women screened had recently experienced or were at risk of intimate partner violence -- these women were not enrolled in the study. There were 12 reports of violence in the intervention arm and 6 in the control arm, but none were considered by the participants or researchers to be related to HIV testing or the study.

Farquhar said that qualitative work showed that the intervention was appreciated for bringing couples together to talk about important issues to do with HIV, pregnancy, and their family. She concluded that a home-based approach is effective in improving male partner testing and is safe. Preliminary analyses also suggest that it is cost-effective, she said.